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Tertiary pattern 5

xxchris47
Posts: 8
Joined: Sep 2010

Had robotic prostatectomy on 8/26/10 I am 63 years old. Nerves were spared (hope that wasn't a mistake). Pathology results were 4+3=7 w/ tertiary pattern 5. Luckily margins and lymph node sampling negative with tumor involving 25% of prostatic tissue. Anybody like this out there? Getting mixed reports on relevance of tertiary pattern reporting but most info implying this is setting me up for a greater liklihood of recurrence. Also it seems with my gleason 7 and the tertiary 5 it's making my gleason in effect a 8 or a high risker. Appreciate any insights.

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Kongo
Posts: 1167
Joined: Mar 2010

Chris, welcome to the forum and happy to see so many positive aspects from your recent surgery. I hope that you are otherwise recovering well.

As you probably know by now, tertiary Gleason scores are a relatively new twist on post RP pathology reports. I know that some institutions, Johns Hopkins being among them, suggest that tertiary Gleason scores become standard procedure.

I didn't have surgery to treat my PCa but as I understand it, tertiary scores of 5 are relatively rare and some researchers have suggested that a Gleason 7 with tertiary 5 is an indicator of future biochemical recurrence as it represents a more aggressive cancer. Like so many aspects of this disease, there is ongoing debate about the impact of a tertiary pattern 5 on the cancer's virulence.

The Gleason scoring system is quite nuanced and most of us laymen tend to look at the scores as absolutes when in fact it's very much open to interpretation, particularly when the cancer is close to being in between one grade or the next. I think that is where the "effective score of 8" might come from as it would be difficult to distinguish a 4+3 with a tertiary 5 from a 4+4.

I would certainly get a second opinion on your post RP pathology report and discuss in detail with your medical team what options you should be considering. I believe that if there is extracapsular extension suspected at the time of surgery (as might be suggested by your tertiary score) that the sooner you initiate follow-on treatment the better the chances of full recovery.

Good luck to you on this.

xxchris47
Posts: 8
Joined: Sep 2010

Thanks for the info. which was extensive. I had no idea about rarity of tertiary 5. That's kind of creepy. Anyway, if I were a betting man I would wager on liklihood of radiation or some other therapy before 3 years given this report. Wondering if there are any studies indicating one way or the other about liklihood of recurrence with these numbers? I would love to believe I could make use of my spared nerves before going through radiation.

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Kongo
Posts: 1167
Joined: Mar 2010

Chris,

Here's one from PubMed:

http://www.ncbi.nlm.nih.gov/pubmed/18076949

Here's a more detailed study from JAMA:

http://jama.ama-assn.org/cgi/reprint/298/13/1533.pdf

Trew
Posts: 892
Joined: Jan 2010

This is a new term for me, at least I don't remember seeing it in any of path reports.

Now I am wondering.... Ah, sucks, I suppose a gleson of 9 just about covers everything. I have enough to worry to about as it is.

142
Posts: 169
Joined: Dec 2009

My post-op path was 4+5, and with positive margins, it sent me to IGRT immediately. (I did not wait for a PSA rise).

Look at a Gleason grading chart example - 5 is fairly ugly.

xxchris47
Posts: 8
Joined: Sep 2010

Thanks for your reply and best of luck to you. I am a little confused, perhaps you can explain. You said yout surgery did not "get it all", yet in Dec. your PSA was 0.000. Why then are you starting radiation? Doesn't 0.00 PSA indicate no evidence? By the way, if I may ask, were your nerves spared in your surgery? Thanks.

142
Posts: 169
Joined: Dec 2009

Chris,
Wasn't sure if the question was for me, but...
My DaVinci resulted with multiple positive margins, so one has to presume there was something left. The optimist will say that the cell they cut was the last one in the string, or that the surgery trauma kills what few might be left. Not a bad philosophy. I'm not a philosopher.

My first post-op (December) PSA was "undetectable", actually <0.1. My Uro does not do ultrasensitive. I've had an ultrasensitive from another lab, "undetectable", actually <0.01. There is no 0.000 with current technology, even if we call "undetectable" the zero club. A liberty we have permitted ourselves.

Radiation was started in late March, so is done now.

Why did I chose adjuvant radiation? I did not want to leave dangerous tissue there dormant to wake up in 6 months or 6 years. I was not interested in finding that I had a new problem when it was too late. What new data there is (a recent study Walsh particpated in) indicates that at my level, the 5 and 10 year cancer-free survival rates are much higher if the RT is started immediately compared to waiting for a PSA rise.

Is that the right choice - Check back in 5 years, I guess. I'll only know if it didn't work.

Nerves were taken in the DaVinci surgery, as they were part of the positive margins.

bdhilton
Posts: 759
Joined: Jan 2010

142,
I believe you did the right thing for yourself. I appreciate your candor and it made me smile-thanks…I elected not to have adjunct radiation. If my PSA goes up then I will do salvage. I had my surgery back on March 3, 2010 (55 years old) and my post surgery pathology (that only guys with surgery can have) report is a Gleason 4+3 with tertiary 5 (some pathologist do not even report this), one positive margin at the right mid, SVI on the right (focal) and the surgeon saved one nerve bundle…

Like you, did I make the right choice? Time will tell but I believe it is and my oncologist supported my decision with the promise of PSA test every 90 days. So far Zeros and I have a test next week that I hope continues the trends but I will see… My spiritual adviser (my priest) told me at the beginning of my journey not put to much faith on statistics and do what I believe is right based on my gut after studying the information available…

Hey you can be the guy with a 97% chance of never having a reoccurrence and if you are one of the 3% where reoccurrence came back in this group then it might had been 100% chance of reoccurrence…
Life is to short to worry about what might happens…enjoy what you have -B

Lindorf
Posts: 11
Joined: Apr 2009

I had RP surgery in March 2009. Post op Gleason 4+3 tertiary 5 with one focally positive margin. 6 week PSA was undetectable. After considering the numbers and statistics I elected to do adjuvant radiation therapy as for me it looked like it would offer about a 25% better outcome than waiting for salvage. As you no doubt have seen there is no single right way to go or obvious choice, just a kind of crap shoot based on other outcomes and best evidence.

6 week and 6 month follow up PSA still undetectable. I had no noticeable side effects from the ART.

I wish you well.

L

bdhilton
Posts: 759
Joined: Jan 2010

Lindorf,

Yes I totally agree that there is “no single right way to go or obvious choice, just a kind of crap shoot based on other outcomes and best evidence...” This is why fighting this beast so convoluted…to many choices and too many “professionals” spinning they snake oil…

Best to you in your journey

xxchris47
Posts: 8
Joined: Sep 2010

Thanks for all the input. I know before my surgery I combed the internet for all things prostate Ca, including getting very familar with Gleason scores, etc. That's why this Gleason pattern 5 with my post op 4+3=7 came as unfamilar territory. I didn't see any references at all on tertiary pattern5. Since I am only 13 days post op and won't get my first blood test until 9/24 (1 month) I know I'm not at the decision making time yet for follow up treatment. Of course, I am grateful for neg. margins and lymph as well as no extraprostatic extension and see from others' experiences how this tilted your decision making. As my surgeon said, "we will watch you like a hawk", so I believe the tertiary pattern 5 sent up a genuine red flag and glad now that it was reported by the pathologist. Though just a beginner in this game I can see however how slippery the slope is with this disease and how important to have your game face on and to be a self advocate. Thanks to you all.

bdhilton
Posts: 759
Joined: Jan 2010

Chris…

Having PCa is a red flag in general...:-)

The only piece of advice I push to anyone are lifestyle changes. I totally changed my diet (at biopsy) and stepped up my workout religiously (at biopsy). These are the only two things from my perspective that you control that have a direct impact on your health today and going forward….

Since you are recovering walk, walk and walk more. At the end of three weeks after open surgery I was walking 50 +miles per week and the doctors removed all limitations from me on week 6 because of my walking and walking more…

I removed all dairy (I have one serving of soy a day) and red meat (I have had steak twice in 6 months) out of my diet and live on a “heart healthy” Mediterranean diet…I eat sockeye salmon, sardines in olive oil or wild caught northern cold water fish….I take a few Vitamins as I believe you can get most from the food you eat . …I also eat a small amount of nuts daily…

Now I also would have given a right or left nut to have had my PCa at 63 instead of 55 as all things are relative but seriously these are the cards that were dealt to me and I hope and pray I just make the right decisions as I go through this journey

Peace and the best to your recovery and journey

lee 67
Posts: 3
Joined: Sep 2010

I just had surgery 9/21/10 .Had robotic prostatectomy, Today had follow up, got my pathology report 4+3=7 and a tertiary 5, the margins and lymph nodes were negative , that is huge because if it gets out us that is were it is most likely to go, My doc told me he wants me to do radiation starting in 6 weeks Lee 67

bdhilton
Posts: 759
Joined: Jan 2010

Lee,

This does not make sense to me based on everything I have read with regards to adjunct radiation. Adjunct (as well as salvage) is typically for positive margins after surgery and you mention you had negative margins. If you are correct then I would be getting a second opinion…

Best to you

lee 67
Posts: 3
Joined: Sep 2010

I thought it didn't make sense either , the pathology report said the tumor was sticking out of the base of the prostate so even though the margins were negative they wanted the radiation done on the prostate bed ,that made sense to me . I spoke with the surgeon and oncologist and they both thought it should be done , so I went with it. Did 39 treatments and have done 2 PSA tests since both are >0.1 some good news finaly.

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lewvino
Posts: 1007
Joined: May 2009

Lee 67,
I am in no means associated with the medical profession but from I've learned on my own prostate cancer journey I would be inclined to wait and not start radiation immediately.

THere are several good books you can read that talk about follow up radiation following surgery. One is the book by Dr. Patrick Walsh who is at John Hopkins.
He has several comments in his book about pro's/con's of follow up radiation.

Do some research and talk to your Doctor about his reasoning for wanting to start so soon and make an informed decision.

Best wish's to you from another Gleason 7.

Larry age 56
surgery Aug 2009, PSA 0 so far.
1 positive margin noted at pathology.

xxchris47
Posts: 8
Joined: Sep 2010

I believe I started the threads re: pattern 5. I got my first PSA results Friday (Oct. 4). Pleased to report with ultra sensitive test it came in at .02, which my doctor was pleased with that--so I'm I. I go back in 90 days for second test. I started discussing ED treatment with him and he wrote prescription for 100mg of viagra. To note I was taking 25-35 mg. of viagra pre surgery (would slice up tabs). I know my chances are so so of getting back "my groove" with previous ED issues. But I have hope, but idea of taking 100mg of viagra isn't appealing due to side effects (that really under the influence of drug sensation). I am not opposed to trying an injection if that would benefit as much as large dose of viagra. Anyway, any comments from anyone concerning this??

lee 67
Posts: 3
Joined: Sep 2010

Hi my name is Lee I had a robotic prostatectomy on 9/21/10. I had a 4+3=7 with a tertiary 5.There was extraprostatic extension,with negative margins and lymph nodes, I had to do 39 days of radiation, since then I have had 2 PSA tests both tests were >o.1. I have to get PSA test every 3 months.I am 52 years old and very optomistic so are the doctors .I was told every case is unique so I don't let statistics and the stuff you read on the internet rent space in my head .

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